Cuba-Venezuela Health Diplomacy: The Politics of Humanitarianism

For decades Fidel Castro has “exported” professionals, mostly doctors,1 to the developing world to serve as “missionaries for the Cuban Revolution.”2 These brigades of “proletarian internationalists,” as they are referred to at home,3 have two primary goals: to earn hard currency and advance other economic goals of the regime and to gain political influence, prestige, legitimacy, and sympathy abroad.4

From the earliest days of Castro’s rise to power in Cuba (on January 1, 1959), efforts to legitimize the revolution centered on delivering healthcare and education to underprivileged and underserved sectors of society, mostly in rural areas. As the Castro regime imposed a Marxist-Leninist model and command economy, free and universal healthcare became a critical pillar of the revolutionary project. After restructuring the economy and recovering from the exodus of many health professionals that occurred immediately after the revolutionary takeover, Cuba again achieved high indicators of human development such as in infant mortality, life expectancy, and doctors per capita.5 These accomplishments, aided by vigorous propagation efforts worldwide, earned Cuba accolades as a model in health and education.6 Serious questions and challenges remain as to whether these “achievements” are exaggerated or misrepresented as a result of propaganda, the manipulation of statistics, and distortions caused by heavy-handed control by a totalitarian state.7 But, that Cuba’s universal health and education systems enjoy an exceptionally favorable international opinion is clear. Cuba’s health diplomacy has grown congruent to that glowing reputation.

Grasping the great benefits to be reaped, Fidel Castro began using health diplomacy as a tool to gain credibility and backing for his regime and help advance its goals internationally. From initial success with international missions for disaster relief, he developed the concept of government-to-government agreements that took Cuban health professionals (mostly doctors) to underserved populations worldwide.8

By 2006 over one hundred governments had signed pacts with Cuba for a sustained presence of Cuban health professionals in their countries: 6 in the 1960s; 22 in the 70s; 11 in the 80s; 47 in the 90s; and 15 since 2000.9 Cuban medical brigades serve in Latin America, the Caribbean, and Africa and have recently been expanding into Asia.10 In July 2003, Fidel Castro wrote that in the previous forty years, 52,000 Cuban doctors and health professionals had served “voluntarily and for free” in 93 countries.11 The official newspaper of the Cuban Communist Party reported in November 2008 that there were 38,544 Cuban health professionals serving in 75 countries, 17,697 of them doctors; the vast majority (29,296) were in Venezuela.12

CHÁVEZ GETS ON BOARD: “OIL-FORDOCTORS” IS BORN

It appears that soon after Hugo Chávez was elected President of Venezuela in 1999, Fidel Castro convinced him of the effectiveness of this peculiar mechanism. Chavez proceeded to greatly expand the initiative as part of a strengthening Venezuela-Cuba alliance.13 Two critical goals would be met with a robust health-for-oil program. First, to aid Cuba’s ailing economy and help keep the Castro dictatorship in power, Chávez would provide subsidized Venezuelan oil to Cuba in payment for the services of the internationalist brigades.14 Second, benefitting traditionally marginalized populations in Venezuela and other developing countries at little or no cost to the end recipients would greatly boost loyalty and support for the Chávez-Castro political agenda in the face of considerable resistance to their revolutionary Marxist project. The fast-tracked arrangements have benefitted Venezuela and other countries, including Bolivia Nicaragua, and Uruguay, which presumably do not pay for the services themselves.

The Cuba-Venezuela cooperation agreements, renewed annually, allow Cuba to pay for part of its bill for substantial Venezuelan oil imports with the services of its professionals abroad.15 In 2002, the first accord between Cuba and Venezuela was signed and around 250 Cuban physicians, nurses, and technicians were sent to Venezuela.16

With Venezuelan support, Cuba quickly stepped up its health diplomacy. Medical missions were sent to Venezuela and other countries and full hospitals and specialized clinics were also established in a growing number of countries. In 2002, 6,190 Cuban health “collaborators” were reportedly serving abroad; by 2005, the number had jumped to 31,24317 and by March 2007, the Cuban government reported that around 40,000 doctors, dentists, nurses, and other medical personnel were working in 69 countries (of which around 15,000 doctors were serving in Venezuela). In December 2008, Venezuela’s Minister of Health reported that 29,296 Cubans were serving there: 13,020 doctors, 2,938 odontologists, 4,170 nurses and 9,168 “health technicians.”18 The number appears to have stabilized; in mid-2010 Cuba reported that around 30,000 doctors, nurses and health professionals were in Venezuela.19

In Venezuela, the Cuban medical mission is part of the “Barrio Adentro” (“inside the neighborhood”) initiative that provides health services and health education in medically underserved communities all over the country. The program has had a huge impact in Venezuela. At the end of 2008, its Health Minister reported that the “Barrio Adentro” initiative had handled 360 million medical consultations since its inception. Claiming that in 1998, before Chávez assumed power, 5 million primary care visits had been handled, he reported that as of the start of December 2008, they were going on 60 million for the year.20 This represents a twelve-fold increase. 10,991 new or refurbished consultorios populares (“Barrio Adentro” outpatient offices) had been established. 21 While there had been one public primary care doctor per 17,300 inhabitants of the country, by 2008 there was one per 3,400 inhabitants.22

The scope of the project has grown vastly, both in cost and reach. Although it is not known exactly which countries benefit from the oil-for-doctors agreements and to what extent, it is presumed that many of the Cuban medical brigades overseas operate, to some extent, as part of the program. Cuban doctors, in addition, train medical students in Venezuela23 and health professionals participate and often lead local courses for midwives and other community- based health personnel and participate in more formal training for paramedical and allied health professionals. 24

Countries whose leftist Presidents have strong ties to Venezuela and Cuba—Bolivia, Ecuador and Nicaragua—seem to be receiving the most favor and at no direct cost to them in order to “support revolutionary change,” as a U.S.-based supporter explains.25 In Bolivia, in particular, the program grew quickly.

Almost immediately after Evo Morales’ election to the presidency in December 2005, 718 Cuban doctors were there as part of a newly-minted Cuba-Bolivia cooperation agreement.26 By April 2008, there were 1,852 Cuban health care workers in Bolivia, 1,226 of them doctors.27

The vision restoration program “Misión Milagro” (Operation Miracle), also launched in 2004, is “a gigantic campaign of a social and humanitarian nature” 28 intrinsic to the greater plan. It provides free eye surgery, mostly for cataracts, glaucoma, myopia, and other eye ailments by either flying people to Cuba or by having Cuban doctors treat patients in their home countries in specialized clinics donated by Cuba and Venezuela.29 The goal is to treat no less than six million economically deprived citizens of Latin America and the Caribbean in ten years.30

At first, only Venezuelans were flown to Cuba for the eye surgeries; soon nationals from other countries were included and ophthalmology centers (eye clinics) were being set up abroad. A dedicated Cuban government website proclaimed that since its inception in July of 2004 through March 2009 almost 1.5 million persons from 35 countries had been treated, including over 267,000 foreigners in Cuba.31 12,000 nationals from Caribbean trade bloc countries, including Jamaica and Grenada, had benefited from the program by 2008.32 From 2006 to 2009 seventy Cuban doctors had performed 90,000 operations in three eye clinics donated by Cuba in southern Ecuador, a staunch ally of Cuba and Venezuela. Some Colombians and Peruvians had also been treated there.33

By October 2008, the Misión Milagro program was operational in over 25 countries, including Argentina, Brazil, Belize, Bolivia, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Mexico, Nicaragua, Panama, Peru, Paraguay, Suriname, Venezuela, Uruguay, Haiti, Antigua, Barbados, Bahamas, Dominica, Grenada, Jamaica, Montserrat, St. Christopher-Nevis, St. Lucia, and St. Vincent and the Grenadines.34 By mid-2009, the Cuban government claimed that 61 eye hospitals with 92 surgery rooms have been “donated” by Cuba to 20 countries of Latin America and the Caribbean plus Angola and Mali.35 The expansion continues. In a four-month period in 2009, there were news reports of the inauguration of the first of seven eye centers planned for Algeria and the second of several planned for China plus plans for a hospital in Qatar.36 In some countries, the program reportedly “receives support from local governments.” 37

ECONOMIC ARRANGEMENTS: THE BUSINESS OF HUMANITARIANISM

Public statements by Cuban government officials obscure the fact that Cuba actually receives payment for many of the medical services, at least those delivered in many countries. How much Cuba is paid for and how much it actually donates is difficult to pinpoint. What seems quite clear, however, is that Cuba does receive compensation, that in recent years most of it has come from Venezuela, and that it has grown to a very high percentage of Cuba’s GDP.

Cuban health professionals serving abroad typically receive a miniscule fraction of the payment Cuba derives from the governments of countries where the health professionals render their services. Many cooperation agreements stipulate payment, a fact that is widely reported by local media and other sources in many recipient countries. Official Cuban sources indicate that “the host country provides accommodations and food, domestic transportation, a locale for work, and a monthly stipend (usually US$150– $200), while Cuban personnel receive their regular salaries, airfare and other logistical support from the Cuban health ministry.38 They do not clarify the source of the funds for Cuba’s outlays.

The Economist Intelligence Unit estimated that between 2003 and 2005, Cuba’s non-tourism services exports, most said to be medical services, grew around US$1.2 billion to a total of US$2.4 billion, by 2005 surpassing tourism revenues.39 Cuban government statistics show a steady and exponential rise in services exports from US$2.8 billion in 2003 to US$8.6 billion in 2008 (see Table 1). Most of these exported services are reportedly related to internationalist medical missions. Cuban officials reported that revenues in 2008 for the services of Cuban professionals abroad totaled around US$6.5 billion.40 Services export data published in the 2007 Annual Report of Cuba’s Central Bank indicated that exports of health and education totaled around US$6 billion.41 This was far more than any other Cuban industry generates and almost three times revenues from tourism.42 A Cuban doctor who served in Venezuela until August 2009 reports that at group meetings, supervisors would tell them that revenues from the internationalist missions were higher than from tourism, tobacco, sugar and nickel exports combined. They were urged to perform well, and “take care of this program because, otherwise, the revolution will collapse.”43

Table 1. Cuba’s Services Exports

For all practical purposes, Cuba’s brand of health diplomacy is possible only in a totalitarian state. Cuba is one of very few countries in the world that limits the right of its people to leave the country at will and does so systematically.44 Making things even more difficult for health professionals, they may not leave Cuba without a ministerial authorization, which is nearly impossible to obtain. Plus, when authorized, they are rarely allowed to travel with their families. The Cuban government argues that this is to protect the investment Cuba has made to educate health professionals. No doubt it also guarantees a steady pool of health professionals as temporary workers, i.e., “exportable commodities.”

To make things more difficult for health professionals who defect abroad or leave the country without government authorization, in January of 20010, the Cuban government passed a resolution forbidding the Ministry of Health from issuing credentials (pertaining to documents on education and work) to doctors who are abroad and dictating that verification of studies requested by U.S. institutions only be issued to individuals authorized by their workplace to go abroad, even if temporarily.45 Previously, doctors who had emigrated through unofficial means had been able to obtain credentials by paying very high fees—in the thousands of dollars—to willing Cuban government officials.46

Because in Cuba, the entire economy, including the health sector, is in the state’s hands, doctors may not practice privately. Pay from their sole employer, the state, barely guarantees subsistence. A doctor who chose to go work in Venezuela in 2006 explained that in Cuba he supplemented his meager salary of 475 Cuban pesos (around US$21.50) by raising pigs and egg-laying hens, though this could have landed him in jail.47 His salary, he insisted, was not enough to live.48 Similar stories are heard from many other doctors.

In order to work overseas, Cuban doctors must agree to contribute a sizeable part of their wages to the Cuban state within the framework of government-togovernment agreements between Cuba and recipient countries. Despite that, many welcome the chance to work overseas to secure material benefits otherwise unobtainable; most look forward to earning far more than the approximately US$20 a month they receive in Cuba. But, when they reach their destination, many are dismayed to see the pay quickly evaporate when adjusted for local prices.49 The stipend they receive in local currency, generally between US$150 and US$375,50 depending on the country, oftentimes barely guarantees basic necessities.51 In Venezuela, for example, it was from US$110 to US$200 per month in 2007.52 Their families in Cuba receive monthly their usual salaries in Cuban pesos (around US$20) plus a sum of US$50 the first six months of service, US$125 from month 6 to month 24, and US$325 thereafter.53 An additional compensation, or bonus, is held in a bank account in Cuba and may only be accessed if the internationalist successfully completes the assignment and returns to the island.54 As an added benefit, the Cuban government allows professionals serving abroad to send home three large boxes per year free of shipping cost and of import duties. This is very enticing, as it allows families to obtain appliances, electronic equipment, and other consumer goods nearly impossible to get in Cuba or only available at prohibitive prices.55

For 2008, Cuba’s reported US$8.6 billion in exports of services; this figure less tourism revenues56 divided by the number of collaborators abroad (38,54457) is equivalent to a per capita revenue per collaborator of US$160,855 per year or US$13,405 per month.58 Reportedly, Cuba is paid for nurses and technicians in the same amount as for doctors. Meanwhile, the average Cuban doctor serving in Venezuela receives a maximum of around US$6 to US$7 thousand a year (US$500 to $580 per month) if he or she returns to Cuba having completed the mission successfully.59 If he or she does not return to Cuba, the annual pay is only around US$2.4 to US$3 thousand,60 equivalent to half the minimum wage in Venezuela.61

In most countries, the Cuban health professionals are typically sent to far-flung areas where local workers refuse to work due to insecurity, remoteness, low salaries, poor conditions and inadequate food. In Venezuela, in particular, Cuban health professionals have been sent to crime-infested areas and the toll has been heavy. Many have been assaulted, raped,62 or killed. In March of 2010, the Cuban and Venezuelan governments honored 68 Cuban doctors who had died in Venezuela during their tours of duty in the previous seven years, presumably as a result of criminal acts.63

The doctors tend to have very heavy workloads, often working from early morning until night, sometimes seven days a week. They regularly live in poor areas in shabby accommodations,64 with local families in cramped spaces or sharing accommodations with numerous co-workers, deprived of privacy and lacking recreational activities, and are not allowed to drive a car. In Venezuela, as neighborhood clinics have been built, more Cuban health professionals live communally in facilities annexed to the clinics and no longer with families.65

Cuban professionals serving abroad are reportedly bound by Cuban laws applicable to all personnel serving overseas.66 Among other things, they are forbidden from accepting gifts or associating with any person in the host country that is not supportive of the host government’s revolutionary program and ideals.67 They have to attend political meetings to hear the official version of the news from Cuba and the world, cannot leave home after a certain hour— say 5 or 7 p.m., allegedly for their safety—and are forbidden to stay out overnight.68 Also, they are required to inform on any co-worker who offends the “honor of the motherland and its symbols” in their presence69 and are not allowed to speak to any member of the media. It is not surprising that a Cuban doctor, now in exile, wryly proclaimed: “We are the highest qualified slave labor force in the world.”70

Some Cuban health workers who volunteer to serve abroad see it as their only chance to escape Cuba. Reportedly, over 2,000 have deserted worldwide;71 almost 1,500 had obtained visas to enter the United States from 2006 to March 2010.72 But, they are under surveillance from their Cuban handlers/supervisors. The level of control seems to vary, depending on the circumstances and location, but the rules are strict across the board. The internationalists are issued a special “official” passport of a different color (red) than all other Cubans that may not bear visas from any other countries in order to prevent travel with this document anywhere but Cuba.73 Often, the passport and other identity documents are retained by their supervisors. If “red alerts” are issued, the doctors may not leave their quarters at all for days. Many have staged dangerous and elaborate schemes to escape their Cuban handlers and seek asylum in different countries.74 In Venezuela, many have fled through the border to Colombia75 and those who attempt to leave through the airport must bribe customs authorities at the airport with hundreds of dollars, which are very tough to come by, to be allowed out of the country without alerting, as per standard orders, Cuban State Security that could force them back to Cuba.76

The systematic lack of most labor rights affecting all Cuban workers is curiously exported with the health professionals sent abroad. A June 2009 report of labor violations in Cuba by the non-profit organization International Task Force on Corporate Social Responsibility in Cuba details a long list of labor abuses, starting with the Cuban state as sole employer and the CTC (Central of Cuban Workers), which is subordinated and controlled by the state and the Communist Party, as the only authorized labor organization, one that Cuban workers are forced to belong and pay dues to. The rights to strike, peaceful protest, direct employment, collective bargaining, and free movement within the country are denied to workers. In addition, workers must participate in public acts and activities organized by the government, “donate” pay to militias, submit to arbitrary measures from supervisors/employers, and face discrimination for political reasons. Those who attempt to organize under independent labor groups face jail, physical violence, mass acts of repudiation, harassment, intimidation, threats, confiscation of humanitarian assistance, restriction of movement, surveillance, exile, detentions, dispersion of meetings, and prohibition from leaving the country.77 The International Trade Union Confederation’s Annual Survey of Violations of Trade Union Rights 2009 eloquently confirms most of this.78

Arguably,79 the agreements between Cuba and host governments—or their consequent practices—for the service of Cuban professionals abroad violate domestic laws of many countries, of a number of international agreements (most having been ratified by Cuba) and of universally accepted standards. The latter include:

The Trafficking in Persons Protocol, which went into force in 2003, but that Cuba has not signed.80 The Protocol states that “Trafficking in persons means “the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, …of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person, for the purpose of exploitation.” (Art. 3, subparagraph a). It also states that: “The consent of the victim to the intended exploitation is irrelevant once it is demonstrated that deception, coercion, force or other prohibited means have been used.” (Art. 3 subparagraph b) In addition it clarifies that exploitation may take the form of labour trafficking. “Exploitation shall include, at a minimum, …forced labour or services, slavery or practices similar to slavery, servitude…” (Art. 3 subparagraph a).

ILO Convention on the Protection of Wages of 1949,81 which states: “Employers shall be prohibited from limiting in any manner the freedom of the worker to dispose of his wages.” (Article 6.) Further, Article 8 reads: “Deductions from wages shall be permitted only under conditions and to the extent prescribed by national laws or regulations or fixed by collective agreement or arbitration award.” Finally, Article 9 reads: “Any deduction from wages with a view to ensuring a direct or indirect payment for the purpose of obtaining or retaining employment, made by a worker to an employer or his representative or to any intermediary (such as a labour contractor or recruiter), shall be prohibited.”

ILO Convention No. 29 Concerning Forced or Compulsory Labor, which calls for the suppression of “the use of forced or compulsory labour in all its forms” and defines forced labor as: “All work or service which is exacted from any person under the menace of any penalty and for which said person has not offered himself voluntarily.” 82

In addition, Cuba’s international medical missions are contrary to universally accepted standards and an international consensus against:

Servitude. Early drafts of the Trafficking in Persons Protocol defined servitude as the status or condition of dependency of a person who is unlawfully compelled or coerced by another to render any service to the same person or to others and who has no reasonable alternative but to perform the service.83

Slavery. “The status or condition of a person over whom any or all of the powers attaching to the right of ownership are exercised.”84

In Febuary 2010, seven Cuban doctors and one nurse residing in the U.S. and formerly in Venezuela filed a lawsuit in Florida against Cuba, Venezuela and Venezuela’s state-run oil company (PDVSA) for forcing them to work against their will and holding them in conditions akin to “modern slavery.” They claimed having been forced into servitude and paid low wages to help repay Cuba’s oil debts to Venezuela. 85

Quality of Care and Other Concerns

The massive and accelerated training of Cuban doctors and health professionals, particularly in recent years, is only possible in a state-controlled society like Cuba, where the government is the sole employer and strictly controls the educational system and the workforce.

Beginning in the 1990s, during the period marking the end of Soviet support and the beginning of a deep economic crisis in the island, Cuba’s twentyone medical schools were revamped, a residency in family medicine was created, and the annual number of graduates was ratcheted up. Fresh doctors were needed to replace those who finished their tours of duty. By 1998, Cuba reportedly had 5.8 physicians for every 1,000 citizens, the highest doctors per capita ratio in the world. In 2007, there were 6.5 doctors for every 1,000 citizens, compared to 3.1 per 1,000 in Western Europe, and 2.4 per 1,000 in the United States.86 By 2005, Cuba’s physician population had reached over 70,00087 and 72,417 as of 2007.88 Furthermore, in 2007 the Cuban government reported that 100,000 Cuban doctors, nurses and other medical personnel were being trained for service in the Third World.89 A strong advocate of the Cuban internationalist effort explains: “Cubans, with the help of Venezuela, are currently educating more doctors, about 70,000 in all, than all the medical schools in the United States, which typically have somewhere between 64,000 to 68,000 students enrolled in their programs.”90 This is a huge number for a population of a little over eleven million and raises concerns regarding quality.91

Doctors and medical associations in Brazil, Bolivia,92 Uruguay,93 Ecuador, Panama,94 Venezuela and Trinidad, 95 among other countries, have protested that the Cuban health professionals lack accreditation to practice in their home countries and have questioned their credentials and experience. Malpractice accusations against Cuban doctors have been reported in Venezuela, South Africa, Zimbabwe, and Haiti.96

Concerns may not be without merit. Allegedly, it is customary to send Cuban doctors still in training to Venezuela and use their time serving there as the practicum needed to issue their degrees in Cuba.97 A Cuban “doctor” reported that he was sent abroad before completing the last two years of his medical training.98 The Association of American Physicians and Surgeons has highlighted Cuba’s poor medical training and reported that only 25% of Cubantrained physicians pass the medical exams required to practice in the U.S.99 Shoddy practices have reportedly been exported through training of Venezuelan doctors by Cubans. A Cuban doctor serving near Caracas who was also required to impart training to local medical students reports that he was required to issue passing grades to students who had performed poorly.100

In some cases, such as in South Africa in the last decade, Cuban health professionals have helped fill vacancies left by local doctors who emigrate looking for better salaries.101 But the international brigades create distortions in some home countries that do have sufficient doctors or have many unemployed or underemployed doctors. Many have questioned the need to bring in foreign doctors if there is a local pool of professionals available with the required credentials. In 2005 in Brazil, sixty-nine Cuban doctors were sent back to Cuba after a judge decided they were occupying positions of local doctors.102 In 2003 a Venezuelan court ruled in favor of the Venezuela Federation of Doctors and ordered that Cuban doctors be replaced by properly qualified and certified Venezuelan doctors.103 The Chavez government refused to abide by the ruling and the growing infringement of the Venezuelan judicial system stymied all attempts to uphold it. In Bolivia, a medical association of unemployed doctors went on strike to protest the presence of the Cuban doctors, but President Evo Morales insisted that the Cubans would stay as long as he was in office.104 Cubans practicing medicine overseas as part of the residential medical missions are subject to discretionary approval from political entities, such as health ministries that answer to the executive power. But, countries where the rule of law is weak and more subservient to the political class will deal with these problems in non-traditional ways.105

Selective Humanitarianism

A logical and regrettable consequence of the huge growth of the Cuban medical missions in such a short time span is that health care inside Cuba has suffered greatly. Dr. Alcides Lorenzo, the head of Cuba’s National Group of Family Medicine, who defected in Mexico, reported in January 2006 that most of the 31,000 doctors who in 2003 tended to family clinics all over the island had been sent abroad, creating a crisis in public health. Reports from Cuba consistently document the serious problems resulting from the absence of doctors.106 The doctors who remain are overworked, grossly underpaid, excessively stressed and not allowed to take vacations.107 Bitter complaints are common and heart wrenching stories abound of suffering patients and their frustrated, outraged, loved ones.108

Many cooperation agreements entered into by Cuba include the provision by Cuba of medicines and medical supplies that its own population lacks. Doctors have endless tales of how in Cuba in order to treat patients, they must come up with creative and unusual solutions in the absence of basic supplies and medications and systemic lack of equipment and failures. 109 In Venezuela, for example, defecting Cuban doctors reported that “boxes and boxes and boxes” of supplies arrived weekly from Cuba via military aircraft while Cubans on the island complain of a severe shortage of medicines and medical supplies.110 Moreover, while foreigners are brought to the island for treatment and hosted at resorts and transported in fleets of new air-conditioned Chinese buses, Cubans must wait hours for decrepit mass transit and endure extremely limited living conditions.111

The anger and frustration of Cuba’s citizens over the paradoxical state of affairs detailed above can find no outlet in their national media or corrected through civil society activism. In Cuba, there is no freedom of press, political dissent is not tolerated, a change of leadership is not possible, and the Communist party and its mass organizations are the only legal venues for political association.

ALLEGIANCE AS GRATITUDE

Julie Feinsilver has eloquently described the benefits to Cuba from its medical diplomacy: “Because good health is necessary for personal well-being as well as societal development, the positive impact of Cuba’s medical aid to other countries has greatly improved both its bilateral relations with those countries as well as its standing and support in a number of multilateral forums. Therefore, as a consequence of its medical diplomacy Cuba has accumulated considerable symbolic capital (goodwill, prestige, influence, credit and power). The resulting symbolic capital may be accumulated, invested and spent just like material capital. Eventually, it can be converted into material capital, which in Cuba’s case has meant both bilateral and multilateral aid as well as trade, credit and investment.” 112

The rewards of restoring people’s health or eyesight cannot be overestimated; its effects are enormous at many levels, beginning with the individual patient. Patients are typically selected from the poorest sectors of society with the help of politically committed or “progressive” community organizations in their home countries. Instant armies of loyalists, if not militants, are, thus, formed in the gentlest, kindest, and most compelling way. As the website guide of the film “Salud” states: “In several countries, such as Honduras, Haiti, Guatemala, Mali, South Africa and the Gambia, there are whole regions where the Cubans have been the first bearers of local physician services to rural, indigenous and other marginalized communities. They also bear the Cuban philosophy of combining population-based public health principles and prevention with clinical medicine.” 113 Steve Brouwer, writing for the socialist publication Monthly Review, explains that, as inspired by the vision of Ché Guevara, “thousands of doctors have been created who are capable of practicing and teaching revolutionary medicine, and they are putting this “weapon” to good use.”114

In Latin America in particular, the compassion of Hugo Chávez and Fidel Castro is constantly emphasized together with the official sponsorship of the program as part of the Bolivarian Alternative for the Americas (ALBA).115 The ALBA seeks the political, economic, and social integration of Caribbean and Latin American countries in “an alternative model to neoliberalism,”116 essentially meaning Marxism-Leninism. Not surprisingly, the proselytizing component of the internationalist missions is well documented.

The international medical missions are an extremely effective tool for advancing the “Bolivarian Revolution,” led by Chávez, of which Fidel Castro is considered intellectual mastermind and elder statesman. Castro has often expounded on the medical brigades as “soldiers of the revolution.” In a 2008 “reflection” 117 oddly titled “Christians without bibles,” he described the health workers abroad as “an exceptional powerhouse” unique to Cuba that, just like the island’s internationalist soldiers, is trained “for combat.” 118 Illustrating the effect on recipient societies as well as the threat to free-market societies, Feinsilver writes: “Rather than a fifth column promoting socialist ideology, these doctors provide a serious threat to the status quo by their example of serving the poor in areas in which no local doctor would work, by making house calls a routine part of their medical practice and by being available free of charge 24/7, thus changing the nature of doctor-patient relations. As a result, they have forced the re-examination of societal values and the structure and functioning of the health systems and the medical profession within the countries to which they were sent and where they continue to practice.”119

Doctors and health associations in recipient countries have pointed to the distorted economics of some of these agreements. Certain arrangements for which information has become public are illogical from an economic perspective. For example, 300,000 Venezuelans and 100,000 people from 28 other nations were flown to Cuba from July 2004 to January 2007 (on Cuban airliners or those of recipient countries) and put up for two weeks at resort hotels, all expenses paid. “I have paid for nothing, not even a cup of coffee,” said a Venezuelan whose 16–year-old daughter had a sagging eyelid lifted by Cuban doctors. Mother and daughter had been put up for 19 days starting with the preoperative office visits.120 Likewise, the Cuban government was flying 12,000 Paraguayans in groups of one hundred for eight days, all expenses paid, including providing all participants—patients and companions—on arrival to Cuba a toiletries kit, clothes, shoes, a telephone card to call their families, and Cuban money for shopping.121 Paraguayan doctors criticized the arrangement, explaining it costs many times the price of an eye operation in Paraguay, which they government could well have hired local doctors to perform. In 2005, a Paraguayan newspaper developed a detailed calculation indicating that the cost of the operations in Paraguay was ten times less than flying patients to Cuba for the planned eight days’ stay.122 Making the situation more bizarre, 163 Paraguayans were inexplicably kept in Cuba for a full month in 2005 for their free eye surgeries, eliciting protests to their government by family members back home.123

These seemingly “irrational” costs of some of these arrangements are best understood in the context of political gains. According to Feinsilver, by the 1970s Cuba’s medical diplomacy had started to earn its election to leadership positions in numerous international organizations, citing specific votes held by the Non-Aligned Movement, the United Nations Security Council, and the United Nations Human Rights Commission.124

Feinsilver also points to Cuba’s long-standing investment in medical diplomacy as pursuing the accumulation of symbolic capital (prestige, influence and goodwill) that would be converted into material capital in the form of trade and aid. It is no secret that, in contrast with worldwide cries to boycott authoritarian regimes such as South Africa and Chile, Cuba trades and receives foreign investment from most of the world.

GEOSTRATEGIC IMPLICATIONS OF THE CUBAN PRESENCE IN VENEZUELA

The majority of Cuban doctors sent abroad are family doctors who have served in a neighborhood setting on the island. They are used to dealing with community mass organizations, local authorities, and neighborhood watch representatives, plus they are accustomed to responding to issues of political mobilization and control. This makes them particularly valuable to advancing the political agenda of the missions and working with the “Bolivarian Committees” set up in Venezuela in the mid 2000s.125

Cuban health professionals in Venezuela are required to actively support political agendas. Posters of Ché Guevara, Fidel Castro, and Hugo Chávez, for example, plaster the clinics run by the Cubans there.126 Leading up to a 2004 recall referendum, the Cuban doctors had to campaign for Chávez; they were required to put up supportive posters in their clinics and to tell patients to vote for him. A defecting doctor reported: “The coordinator told us that our job was to keep Chávez in power.”127 A Cuban doctor serving in Venezuela during the February 2009 referendum (on whether Chavez could seek indefinite reelection) reported they had been required to monitor electoral centers and call in their observations to their superiors. They had also been asked to seek out people and make them vote and to keep clinics open on the holiday to showcase their free services and indirectly seek electoral payback.128 A doctor who served in Venezuela and defected in 2007 explained: “It is as simple as this: You begin distributing vitamins to the population at a crucial time in the elections. (…) People know who delivers the vitamins, they know where they come from, and they know who’s paying for them, so they quickly decide who they vote for if vitamins are important for them. And for most people, they are.”129

The Venezuelan Medical Federation has charged that Cuban health professionals are “proselytizing” poor Venezuelans with communist propaganda.130 In fact, an independent journalist in Cuba reported in 2005 that six hundred members of paramilitary groups from central provinces were receiving intensive instruction in medical specializations at the “Abel Santamaría” School for Social Workers in Santa Clara with the purpose of sending them to Venezuela.131 In November 2009, another independent journalist from Cuba reported interviewing a doctor sent back to the island from Venezuela for not obeying orders after serving for two years. The doctor claimed that, among the doctors sent abroad, a number is trained by Cuba’s intelligence services to monitor the host country and, in particular, the state of public opinion with respect to the Cuban government. They are also taught to diffuse opposition to the socialist model and spread propaganda favorable to the Cuban regime. 132

By 2010, the Cuban presence in Venezuela was well established and seemingly “sanitized.” At the end of May 2010 Cuba reported that around 30,000 of its doctors, nurses and health professionals were in Venezuela and around 95% of the approximately 40,000 Cubans there were working in health, education, sports or cultural programs “helping in areas that go from agriculture to software design for the stateowned telecommunications company.”133

This certainly had opened the door for the February 2010 arrival of Cuban Minister Ramiro Valdés for a reported long stay as “consultant.”134 Regarded as the third ranking member of Cuba’s ruling elite, Valdés’ official mandate was to head a commission to resolve Venezuela’s acute electricity shortage. But he lacked expertise in that field and Cuba has little to offer given its infamous 12–hour blackouts. But the 77–year old Valdés did have plenty of experience “managing the repressive organs of a police state.”135 Having established Cuba’s ruthless political police in the 60s and having served as Interior Minister twice, his most recent job in Cuba was Minister of Communications, where he policed Cubans’ access to the internet.

Opponents of Hugo Chávez’s regime revived cries against the “cubanization” of their country. Cuban advisors, it was widely claimed, had been placed in Venezuela in sensitive and strategic areas including digital radio communications for Venezuela’s security forces, training of police and security forces, and public registrar and notary offices.136 In April 2010, former Chávez aide and newly retired Brigadier General Antonio Rivero publicly denounced the “meddling” by Cuba “at the highest levels in vital areas that compromised Venezuela’s national security.” He alleged that this included teaching military doctrine at the command level and being present in divisions such as military engineering. Rivero said his critique “a matter of sovereignty” and also explained that the Cuban regime was interested in keeping Chávez in power “because Chávez gives them oil.”137

The Economist echoed Rivero’s claims and reported that Venezuela’s new national police force and army had both adopted policies inspired by Cuba and that Cuban agents occupied key posts in Venezuela’s military intelligence agency.138 Moreover, it claimed that in certain ministries the Cuban advisers appeared to wield more power than Venezuelan officials and that trade unions, particularly in the oil and construction industries, had complained that “oil and petrochemicals are completely penetrated by Cuban G-2,” Cuba’s intelligence service. There were other credible reports that hundreds of Venezuelan youth were being trained in Cuba in the tactics of social repression and political control that Cuba had learned from the former KGB and Stasi (the training ranging in duration between six months and one year).139

FOOTNOTES

1. Cuba has sent professionals and technicians mostly in the field of healthcare, but also teachers, engineers, architects, and specialists in other fields.
2. Miguel Cabrera Peña, “La Nueva Operación Carlota,” Entrevista a Francisco León, Revista Encuentro, Nro. 43, invierno de 2006/ 07.
3. Julie Feinsilver, Healing the Masses: Cuban Health Politics at Home and Abroad (Berkeley and Los Angeles: University of California Press, 1993) 163.
4. Julie Feinsilver, U.S. author of a major work on Cuban health politics, fittingly calls this “symbolic capital.” Ibid.
5. Feinsilver indicates that it is “symbolically important for Cuba to compare favorably with the U.S. in an effort to demonstrate what Fidel sees as the moral superiority of Cuba’s social development policies.” Julie Feinsilver, “The Cuban Threat: Medical Diplomacy,” 1 November 2006. Scoop Independent News, http://www.scoop.co.nz/stories/WO0611/S00005.htm.
6. By the 1950s, Cuba enjoyed very high levels of health and education by Latin American standards and, in some instances, by world standards. For example, according to United Nations statistics, Cuba’s infant mortality rate of 32 per 1,000 live births in 1957 was the lowest in Latin America and the 13th lowest in the world. In 1957 Cuba ranked third in Latin America with respect to physicians and dentists per capita, behind only Uruguay and Argentina—both more advanced than the United States in this measure. Cuba’s 128 physicians and dentists per 100,000 people in 1957 was the same as the Netherlands, and ahead of the United Kingdom (122 per 100,000 people) and Finland (96). See “Zenith And Eclipse: A Comparative Look at Socio-Economic Conditions in Pre-Castro and Present Day Cuba,” Bureau of Inter-American Affairs, U.S. Department of State, January 12, 1998 <http://www.globalsecurity.org/wmd/library/ news/cuba/wwwh0013.htm>.
7. The literature on this is extensive. See for example Jay Nordlinger, “The Myth of Cuban Health Care,” National Review Online, July 30, 2007; Dr. Darsi Ferrer, “The Cuban Health System After Half a Century of Revolution,” Havana, May 8, 2009.
8. “Cuba & the Global Health Workforce,” citing: Memo to Gail Reed from Dr. R. Bagarotti, Unidad de Colaboración Médica, Ministry of Public Health, Havana, March, 2004.
9. “Cuba & the Global Health Workforce,” citing: Memo to Gail Reed from Dr. Ricardo Bagarotti, Unidad de Colaboración Médica, Ministry of Public Health, Havana, June 26, 2006; Speech by Ahmed Maamar, Algerian Ambassador to Cuba, May 24, 2003, Astral Theater, Havana (40th anniversary of Cuban medical team’s arrival in Algiers); and “Mirando al futuro desde la Cooperación Internacional,” Power Point presentation by Dr. Yiliam Jiménez, 26 June 2006, Havana. (Data on how many pacts are currently in place is not available.)
10. Cuba sent ‘doctors to Pakistan after the 2005 earthquake in that country (Canadian Network on Cuba, November 21, 2005, http:/ /www.canadiannetworkoncuba.ca/Documents/Pakistan05.shtml) and has announced it will expand the Operación Milagro into Asia. (“Cuba ampliará “Operación Milagro” a Asia y Africa”, Associated Press, La Habana, 12 de septiembre 2006.)
11. “Los pueblos dirán la última palabra,” Versiones Taquigráficas, Consejo de Estado (“Cuba demanda sustitución de organismos financieros internacionales,” Prensa Latina, La Habana, 5 febrero 2003.) Discurso pronunciado por el Comandante en Jefe Fidel Castro Ruz, Santiago de Cuba, 26 de julio del 2003. http://www.jrebelde.cubaweb.cu /2003/julio_septiembre/jul-27/lospueblos.html.
12. Steve Brouwer, ‘The Cuban Revolutionary Doctor: The Ultimate Weapon of Solidarity,” Monthly Review, January 2009. http:// www.monthlyreview.org/090112brouwer.php. Brouwer is citing Granma, November 3, 2008.
13. In 2000 Cuba and Venezuela signed their first cooperation agreement, which established the basis for what has been a growing and strengthening economic and political alliance.
14. Fidel Castro had already used Cuban medical services as “payment” in the case, for example, of the former Soviet Union, with which Cuba had a debt of over US$20 billion in addition to having received huge direct assistance over nearly three decades. At the end of 1989, as the Soviet Union was leaving Communism behind and pressuring Cuba for repayment, Castro offered to treat children from Russian and Ukraine victims of radiation from the Chernobyl nuclear accident, reportedly free of charge. Some analysts believe there was more to it than humanitarian concern. By 2009, 24,000 Chernobyl victims had been treated. The program has evolved into a cooperation agreement between Cuba and Ukraine whereby Ukraine continues to cover transportation and will begin assigning US$800,000 each year to cover costs, but Cuba’s costs are estimated to be much higher and the services provided in Cuba would allegedly be much more expensive at home. (Feinsilver 2006, 166; Ukraine to Help Fund Cuban Program for Chernobyl Children, http:// www.ahora.cu/english /index. php?option=com_conten…; Andres Schipani, Children of Chernobyl find sanctuary in Cuba, The Age (Australia), July 4, 2009; Patricia Grogg, Chernobyl Kids Keep Arriving in Cuba, IPS/IFEJ, Havana, May 7, 2009, http://ipsnews.net/ news.asp?idnews=46754..
15. In 2008 Venezuela exported 115,000 barrels of crude oil to Cuba per day, part of which was payable in 90 days, the rest could be deferred and was financed by Venezuela for 25 years at 1% interest with a 2 year grace period. Financing was 40% when oil prices were over US$50 a barrel, 50% when over US$80 a barrel, and 60% when over US$100). (Rolando H. Castañeda, “La ayuda económica de Venezuela a Cuba: Situación y Perspectivas, ¿Es sostenible?,” Cuba in Transition—Volume 19 (Washington: Association for the Study of the Cuban Economy, 2009). Cuba can pay for oil imports with the services of Cuban health professionals, teachers, sports trainers, tourism and exchange students that Cuba sends to Venezuela and other countries as part of its alliance with Venezuela in the ALBA (Bolivarian Alliance), but it is not clear exactly how this works.
16. Marc Lifsher, “Cuban Doctors in Venezuela Add To Rift Growing Between Classes,” The Wall Street Journal, May 13, 2002.
17. The Pan-American World Health Organization reported that 84,797 Cuban health “collaborators” served abroad during the period 2001–2005: 4,317 in 2001, 6,190 in 2002, 17,033 in 2003, 26,014 in 2004 and 31,243 in 2005. (PAHO, Vol. II, Cuadro 5, p. 284 http://www.paho.org/hia/archivosvol2/paisesesp /Cuba%20 Spanish.pdf#search =%22 cuba%22).
18. “MinSalud desmiente a Provea: 30 mil médicos, odontólogos y técnicos cubanos están en Venezuela,” 10 diciembre 2008, http:// www.radiomundial.com.ve/yvke/noticia.php?t=16023.
19. “Cubanos en Venezuela: ¿Ayuda o interferencia?,” Caracas, Associated Press, May 31, 2010.
20. “MinSalud desmiente a Provea.”
21. Brouwer.
22. Ibid.
23. Personal interview with a Cuban doctor who defected from Venezuela in August 2009, New Jersey, November 21, 2009. The name is withheld to protect family members in Cuba. The clinic where this doctor worked, in a state near the capital, was staffed with around 20 Cuban doctors, some of whom also trained 22 Venezuelan students completing their 5th year of medicine studies (they graduate after completing 6 years).
24. “Cuba & the Global Health Workforce,” citing: “Mirando al futuro desde la Cooperación Internacional,” Power Point presentation by Dr. Yiliam Jiménez, 26 June 2006, Havana.
25. Brouwer.
26. “Médicos cubanos ayudan a campesinos de Bolivia,” Associated Press, La Paz, 24 de abril de 2006.
27. Fidel Castro Ruz, 25 de Abril del 2008, digital@juventudrebelde.cu.
28. As reported in the Cuban official press. See Alfredo Boada, “Operación Milagro: La cura de millones de latinoamericanos,” Agencia Prensa Latina, La Habana, 7 diciembre del 2006.
29. Public reporting on who the donor is varies. In Cuba’s official press, Cuba is usually presented as the donor, as Cuban personnel staffs the facilities and inputs come from Cuba. Nonetheless, presumably Venezuela is providing the funding. The Venezuelan role is publicized depending on the venue. The “Misión Milagro,” for example, is openly presented as a joint Cuba-Venezuela initiative.
30. “Médicos cubanos operarán de la vista gratis a 12.000 panameños,” EFE (Terra Actualidad), 22 de noviembre de 2005.
31. Persons treated: Caribbean: 65,714, Cuba: 173,793, Venezuela: 635,401, Other Latin America: 668,532, Angola: 4,508, Mali: 6,714. (Cuba Coopera (Cuban government website on international cooperation), http://www.cubacoop.com/cubacoop/misionmilagros. htm.)
32. Guyanese fly to Cuba for free eye care, Associated Press, Georgetown, Guyana, October 1, 2008. (More than 5,000 Guyanese, had been flown to Cuba by October 2008 for free eye surgeries by 2008.)
33. “Operados 90 mil ecuatorianos por médicos cubanos de la Misión Milagro,” Prensa Latina, Quito, 26 de julio de 2009. Cuba Coopera, http://www.cubacoop.com/cubacoop/2009/09–07–28–Operados.html.
34. Boada.
35. 23 in Venezuela, 15 in Bolivia, 3 in Ecuador, 3 in Guatemala, 2 in Haiti, 3 in Honduras, 1 in Panama, 3 in Nicaragua, 1 in Paraguay, 1 in Uruguay, 1 Peru, 1 in St. Lucia, 1 in St. Vincent y 1 in Suriname, 1 in Mali, and 1 in Angola. No precise date is provided. (Cuba Coopera.)
36. Mirta Ojito, “Cuba reaps goodwill from doctor diplomacy,” The Miami Herald, August 17, 2009.
37. Cuba & the Global Health Workforce: Health Professionals Abroad (Website for the film Salud), http://www.saludthefilm.net/ns/ index.html.
38. Ibid.
39. Feinsilver 2006.
40. Castañeda, citing: “El gobierno dice que los servicios dejaron ingresos por 9.000 millones de dólares en 2008,” Cubaencuentro, 9/1/ 2009. (The amount is derived from a reported figure of US$9 billion in services for 2008, minus the reported US$2.5 billion in revenues from tourism.) The Spanish news agency EFE reported the value of these services to Cuba in 2007 was in the order of $2.5 billion per year. (Mar Marin, “Cuba may seek foreign investment in strategic sectors,” EFE, Havana, July 4, 2007.) Meanwhile, Julie Feinsilver told The Miami Herald that more than 31,000 Cuban health workers—most of them doctors—in 71 countries brought Cuba US $2.3 billion in revenues in 2008. Her source is not cited. (Mirta Ojito, “Cuba reaps goodwill from doctor diplomacy,” The Miami Herald, August 17, 2009.)
41. Lorenzo L. Pérez, “The Impact of the Global Financial and Economic Crisis on Cuba,” Cuba in Transition—Volume 19 (Washington: Association for the Study of the Cuban Economy, 2009.
42. Tourism revenues in 2008 totalled US$2.4 billion. (Anuario Estadístico de Cuba, http://www.one.cu/).
43. Telephone interview with Cuban doctor, name withheld to protect family in Cuba, 11/24/2009.
44. Article 216 of Cuba’s Penal Code (Ley No. 62, 29/12/1987) forbids citizens from leaving the country without government permission and punishes attempts to do so with1 to 3 years of prison. Average citizens must face a restrictive, onerous and very costly procedure to obtain authorization to travel. This is in open violation of the Universal Declaration of Human Rights as well as numerous international agreements and customary law.
45. Resolución Ministerial No. 1, República de Cuba, Ministerio de Salud Pública. Michel Suárez, “Bloqueada la legalización de títulos para médicos emigrantes,” 19 febrero 2010, http://www.diariodecuba.net/cuba/81–cuba/342–bloqueada-la-legalizacion-de-titulospara- medicos-emigrantes.html
46. As related to the author by several doctors in exile on a number of occasions.
47. The Cuban Constitution only recognizes property of the socialist state, thus, essentially all means of production are in state hands and all workers are employees of the state. Economic activity outside of state control is punished with prison, yet the underground economy is huge because the official economy cannot guarantee subsistence for the average citizen. Countless thousands are in jail for economic “crimes.”
48. Personal interview with Cuban doctor, 11/21/09.
49. Juan Forero, “Cubans on Medical Aid Mission Flee Venezuela, but Find Limbo,” The Washington Post, February 20, 2007, A7.
50. Feinsilver, cited in Ojito. The pay varies per country, but was reportedly as low as US$50 per month in many countries in Africa and Latin America during the early 2000s. (Maseda and Díaz.) In October 2009, a Cuban doctor working in Venezuela was paid in local currency the equivalent of US$150 (350 bolivares) a month. His monthly salary in Cuba before he left in 2006 was 475 pesos, equivalent to US$21.50, which he had to complement with another job and black market activities. (Personal interview with Cuban doctor, 11/21/09.)
51. A doctor who served in Venezuela for three years until August 2009 reported that with the stipend they had to cover all food, transportation, toiletries and personal effects, telephone, gas for cooking, and anything that broke or needed to be purchased in the housing provided for them at no cost. He lived in a separate section of the clinic with the other 20 Cuban doctors working there. (Personal interview with Cuban doctor, 11/ 21/ 2009.)
52. The Washington Post reported $200. (Juan Forero, “Cubans on Medical Aid Mission Flee Venezuela, but Find Limbo,” The Washington Post, February 20, 2007; A07.) The head of the “Barrio Afuera” program, a non-profit group in the U.S. that helps Cuban doctors who defect, reported that it was 400,000 bolivares, which was equivalent to US$110 to US$160 depending on the existing exchange rate. (Dr. Julio C. Alfonso, Telephone interview, September 15, 2009.)
53. Personal interview with Cuban doctor, 11/21/09.
54. A Cuban doctor working in Venezuela from 2006 until August 2009 reported that his family in Cuba received US$50 per month the first 2 years he was abroad, an amount that increased to US$100 monthly after that. In addition, US$125 per month was deposited in a special account in Cuba for the first six months of service, an amount that increased to US$225 per month until the 24th month of service and to US$325 per month after that. This fund is only made available if the doctor returns to Cuba in good standing after having completed the mission successfully. (Personal interview with Cuban doctor, 11/21/09.) Another doctor who served nine months in Venezuela until arriving in the U.S. in August 2008 reported that his family in Cuba had received monthly US$50 plus his old salary of 505 Cuban Pesos, equivalent to around US$22. In addition, his reserve fund would have accumulated around US$2,000 in the first year, but he forfeited that amount by leaving for the U.S. while serving in Venezuela. In the first three months of his stay, his monthly stipend was 715 bolivares, out of which 50 were subtracted on the spot for a “common fund,” an amount insufficient for his food and basic necessities. (Dr. Keiler Moreno, Telephone interview, January 9, 2010.) This net monthly stipend of 660 bolivares was equivalent to US$307.
55. It was reported, however, that the shipment of these parcels is almost a year behind schedule and that often the boxes are mishandled and the goods arrive broken, with no compensation to the sender. (Personal interview with Cuban doctor, 11/21/09.)
56. This assumes that Cuba reports export of services including tourism revenues, although that is not a certainty. According to a Reuters report filed from Havana: “Cuba does not specify what it includes within the service export category, though officials have said tourism and related revenues, the export of medical and other technical services and donations fall within it.” (Mark Frank, “Cuba says exports of services tops $9 billion,” Reuters (posted in Havana Journal as “Export of Cuba services generate $9billion in 2008 but numbers are suspect,” January 8, 2008 http://havanajournal.com/business/entry/cuba-says-export-of-services-generate-9billion-in-2008– but-numbers-are-susp/).
57. Brouwer.
58. Other economists have calculated that Cuba is receiving from Venezuela the equivalent of US$220,500 per health professional per year. See Castañeda, who also cites renowned economist expert on Cuba, Carmelo Mesa Lago.
59. Calculated as US$150 per month paid in Venezuela, plus $100 per month paid to the family in Cuba and US $325 per month set aside in a fund for when they return. However, only US$50 per month is paid to the family and US$125 set in the fun the first six months of service. The fund goes up to US$225 per month between months 6 and 24, thereafter rising to US$325 per month. (Personal interview with Cuban doctor, 11/21/2009.)
60. Castañeda and personal interview with Cuban doctor, 11/21/2009. (US$2.4 to US$3 thousand was calculated as US$600 to US$1,200 paid to the family in Cuba, depending on the length of service, and the equivalent of US$1,800 paid in local Venezuelan currency.)
61. As of September 1, 2009, Venezuela’s minimum wage was 960 bolivares (U.S.$447) per month, equivalent to US$5,364 per annum. (James Suggett, “Venezuela Invests Surplus Oil Dollars in Education, Housing, and Industry,” September 3, 2009, venezuelanalysis. com.)
62. “Chávez pide perdón a Cuba por asalto y ultraje de dos médicas en Venezuela,” Caracas, Punto de Noticias / EFE, 13 Noviembre 2005.
63. The Cuban Vice Minister of Health, Joaquín García, attended a ceremony in Caracas commemorating the 7th anniversary of the Barrio Adentro program. (“Reconocen muerte de 69 médicos cubanos en Venezuela,” El Universal, Caracas, 16 de abril, 2010.)
64. Dr. Keiler Moreno lived by himself in an attic-type facility over the small clinic he staffed in Miranda state in Venezuela from November 2008 to August 2009. He reports that the ceiling was so low he would hit his head if he stood up and the heat was so stifling he could not remain in his room. The conditions, he said, were the worst he had endured, and this was after living in Cuba, including serving one year alone in a remote rural clinic in the Sierra Maestra.
65. Personal interview with Cuban doctor, 11/21/2009.
66. A Cuban doctor referred to it as Law 38, but the author has been unable to obtain the text of this law or regulation.
67. Ibid.
68. Ojito and personal interview with Cuban doctor, 11/21/09.
69. Ojito.
70. Dr. Julio C. Alfonso co-founded in 2004 the non-profit organization “Barrio Afuera” (Out of the Neighborhood) to help Cuban doctors who defect all over the world with legal and humanitarian assistance. He is in exile, living in Miami. See http://barrioafuera. com. (Telephone interview.)
71. Telephone interview with Dr. J. Alfonso.
72. As of 3/31/2010 the U.S. government had granted 1,477 primary visas under the “Cuban Medical Professional Parole Program” (CMPP). (Kristin Alderman, U.S. State Department, citing a Homeland Security Report, as conveyed by telephone to the author on 3/ 31/10.)
73. Personal interview with Cuban doctor, 11/21/09.
74. In August 2006, the United States announced the “Cuban Medical Professional Parole Program” (CMPP), to grant Cuban doctors, nurses, administrators, lab technicians and other professionals working in third countries under the direction of the Cuban government entry into the U.S. Technically, they are “paroled” by the U.S. Citizenship and Immigration Services, which exercises its discretionary authority to parole an alien into the United States for urgent humanitarian reasons or significant public benefit. (See Fact Sheet: “Cuban Medical Professional Parole Program,” Department of State, January 26, 2009, http://www.state.gov/p/wha/rls/fs/2009/ 115414.htm.) The Cubans must apply at their host country’s U.S. embassy; after undergoing a background check, most applicants are reportedly accepted. (Tal Abbady, “Hundreds of Cuban medical workers defecting to U.S. while overseas,” Sun-Sentinel, October 10, 2007.) At least 500 doctors have escaped in Venezuela in recent years. (”E.U. rechaza a médicos cubanos que desertaron en Venezuela,” Associated Press, Bogota, 4 febrero 2007.) The parole gives those admitted legal status that allows them to work and one year later they are eligible for full residency. Numerous media and other reports have been filed on the defections, many in recipient countries. See for example: Susan Kitchens, “Castro’s Medical Mercenaries,” Forbes, November 14, 2005; Todd Bensman, “Cuba uses humanitarian aid in fight for foothold in Africa,” The Dallas Morning News (Luanda, Angola), May 9, 1999, p. 14A; Mijail Barzaga Lugo, “Reality Different Than Expected for Cuban Physician,” CubaNet, Havana, February 8, 2000, (UPECI, February 5, 2000; Webster Malido, “Cuban Envoy Explains Conditions Of Its Docs,” The Post of Zambia (Lusaka), Africa News Online, July 6, 2000; Chris Gaither and Sandra Márquez García, “Cuban doctors vanish in Zimbabwe,” The Miami Herald, June 6, 2000; Stephen Dudley, “Cuban doctors defect, speak out,” The Miami Herald, Cartagena, Colombia, 15 August 2006; Héctor Maseda, “Esclavos internacionales,” CubaNet, La Habana, 14 marzo 2003; Guillermo Fariñas Hernández, Cubanacán Press, “Médico de Villa Clara critica planes de salud en reunión oficial,” Santa Clara, 26 de abril 2004 (www.cubanet.org).
75. “Al menos dos mil médicos cubanos han huído desde Venezuela a EE.UU. vía Colombia,” EFE, Bogotá, 18 abril 2010; “Médicos cubanos que trabajan en Venezuela huyen del régimen de Castro a través de Colombia,” El Tiempo, 18 de abril de 2010; “Un ‘Ángel de la libertad’ venezolano ayuda a los cubanos a salir por Cúcuta,” El Tiempo, 18 de abril de 2010.
76. A recent deserter from Venezuela claimed he only paid US$50 plus 300 bolivares to airport customs’ representatives, as this is what he had on him. However, another defecting doctor leaving on the same flight for Miami paid US$300 while a friend who left earlier had paid US$800. (Personal interview with Cuban doctor, 11/21/09.) Also see, “Médicos cubanos logran desertar desde Venezuela tras sobornar a funcionarios,” EFE, 7 enero 2010; Casto Ocando, “Médicos cubanos compran su fuga desde Venezuela,” El Nuevo Herald, 7 enero 2010: “Un médico cubano objeto de trato cruel, inhumano y degradante en el aeropuerto de Maiquetía, Venezuela,” Medicina cubana, 6 enero 2010 , http://medicinacubana.blogspot.com/2010/01/un-medico-cubano-objeto-de-trato-cruel_06.html.
77. “Reporte de Violaciones Laborales Cometidas por el Gobierno Cubano,” julio 2009, Grupo Internacional Para la Responsabilidad Social Corporativa en Cuba, http://www.cubasindical.org/docs/reporte2009GIRSCC.pdf.
78. Direct citations from the report: “The State controls the labour market and decides on pay and working conditions in the State sector.” “Freedom of association is restricted and collective bargaining and the right to strike are not recognised by law.” “The government explicitly prohibits independent trade unions.” “Workers can only belong to the single trade union.” “The country has a unique system of labour relations, with the State playing the role of all social actors.” “The bodies that deal with the administration of labour are also part of the leadership structures of the State apparatus.” “There is no legislation covering the right to strike” and actual practices and regulations are “tantamount to denying the right to strike, according to international labour standards.” “Labour disputes are settled by State institutions.” International Trade Union Confederation (ITUC), Annual Survey of Violations of Trade Union Rights 2009, http://www.cubasindical.org/docs/d06100901_e.htm.
79. Although it is clear to the author that Cuba’s international medical missions are in violation of international agreements and standards and numerous individuals and groups have denounced this—including at the United Nations and the ILO—the author is not aware of any rulings by international organizations or tribunals that specifically cite Cuba as violating international rules. In addition, although claims against Cuba have been brought in local courts in several countries relative to the international medical missions, the author is unaware of any rulings finding Cuba in violation of international agreements.
80. Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women And Children, Supplementing the United Nations Convention Against Transnational Organized Crime. The Convention was adopted by resolution A/RES/55/25 of 15 November 2000 at the fifty-fifth session of the General Assembly of the United Nations and entered into force December 25, 2003. Cuba ratified the Convention on 9 Feb 2007, but had not ratified the Protocol as of Sept. 10, 2010 (United Nations Treaty Collection, STATUS AS AT: 09–10–2010 < http://treaties.un.org>).
81. Convention Concerning the Protection of Wages (No. 95), adopted 1/7/1952, which went into force on 9/24/1952 and was ratified by Cuba on 4/29/1952. This Convention was partially revised in 1992 by Convention No. 173.See ILOLEX – database of International Labour Standards and recommendations, including ratification information. http://www.ilo.org/ilolex/cgi-lex/convde.pl?C095 and http://www.ilo.org/ilolex/english/convdisp1.htm.. Cuba is a member of the ILO, which has standards to protect workers with respect to freedom of association, collective bargaining, wages, working time, occupational safety and others, that would serve as guidelines for an assessment.
82. ILO Convention 29 Concerning Forced or Compulsory Labour, adopted in Geneva on 5/28/1930, entered in force on 1/5/1932, and ratified by Cuba on 7/20/1953. http://www.ilo.org/ilolex/english/convdisp1.htm.
83. Combating Trafficking in Personas: A Handbook for Parlamentarians, United Nations, No. 16, 2009.
84. League of Nations 1929 Slavery, Servitude, Forced Labour and Similar Institutions and Practices Convention.
85. “Medical Workers File Suit Against Cuba/Venezuela,”CBS News, Miami, February 22, 2010; “Siete médicos cubanos demandan a Cuba y Venezuela por ‘esclavitud moderna,’” EFE/El Nuevo Herald, 22 febrero 2010.
86. Brouwer. Figures for Western Europe and the United States are from the OECD.
87. “Cuba & the Global Health Workforce,” citing: Gail Reed. Challenges for Cuba’s Family Doctor-and-Nurse Program. In MEDICC Review, Vol 11 No 3, 2000; Castro, F. Speech at national medical school graduation ceremonies, August 13, 2003 (unpublished transcript); and Health Human Resources Trends in the Americas: Evidence for Action, Pan American Health Organization Human Resources for Health Unit, September 2006, Washington DC., p. 6.
88. Brouwer.
89. Pablo Bachelet, “U.S. program for defecting Cuban doctors a success,” The Miami Herald, March 11, 2007.
90. Brouwer.
91. Hilda Molina, “El mito del sistema de salud cubano: un testimonio personal,” 22 mayo 2006. Cato Institute, http://www.elcato. org/publicaciones/ensayos/ens-2006–05–22.html..
92. “Médicos bolivianos dicen que colegas cubanos no deberían ejercer,” Terra España, 11 de marzo de 2006. Mery Vaca, “Medicina gratis como protesta,” BBC, La Paz, Bolivia, 16 de agosto de 2006, http://news.bbc.co.uk/hi/spanish/ latin_america/newsid_4796000/ 4796971.stm.
93. “Uruguay no suspenderá los viajes a Cuba para cirugías oculares,” AFP, Punto de Noticias, 28 de mayo de 2006. “Oftalmólogos cubanos dispuestos a ir a la cárcel en Uruguay, dijo Fidel Castro,” 11 de junio, 2006 – Año 10 – Nro.2216, http://www.larepublica. com.uy/politica/213636–oftalmologos-cubanos-dispuestos-a-ir-a-la-carcel-en-uruguay-dijo-fidel-castro.
94. “Gremio de médicos de Panamá rechazó contratación de oftalmólogos cubanos,” AFP, Panama, March 2, 2007.
95. “Médicos cubanos ‘son amenaza’ para salud de trinitarios,” El Universal, Venezuela, octubre 4 de 2003.
96. Feinsilver 2006.
97. As reported by Dr. Julio Cesar Alfonso (telephone interview).
98. Víctor Llano, “Propiedad del gobierno,” Libertad Digital, Opinión, 8 de marzo del 2003, http://www.libertaddigital.com/php3/ opi_desa.php3?cpn=12667.
99. “Medical Journal Exposes Cuba’s Failed ‘Doctor’Diplomacy,’” Washington, U.S. Newswire, Association of American Physicians and Surgeons, October 12, 2000.
100. Personal interview with Cuban doctor, 11/21/09.
101. Stephanie Nieuwoudt, “South Africa: Cuban doctors provide care in far-flung regions,” IPS/GIN, Cape Town, South Africa, April 28, 2008.
102. “Médicos cubanos vuelven a La Habana por decisión judicial,” Terra España, 15 de abril de 2005.
103. “Venezuela: fallo contra médicos cubanos,” 22 agosto 2003, BBCMundo.com, http://news.bbc.co.uk/go/pr/fr/-/hi/spanish/ latin_america/newsid_3173000/3173645.stm.
104. Feinsilver 2006.
105. Foreign graduates from the medical schools in Cuba, however, must take Cuba’s National Final Examinations, proceed to complete an internship in their home countries, take the local qualifying exam and have their credentials validated there. Ibid.
106. Wilfredo Cancio Isla, “En crisis la salud en Cuba por misiones de médicos,” El Nuevo Herald, 6 enero 2006. Numerous independent journalist reports are regularly filed on this matter. See, for example, Marta Beatriz Roque, “No hay especialistas,” La Habana, Red de Comunicadores, www.cubanet.org, 7 de enero 2010.
107. Francisco Chaviano González, “El abuso contra los médicos cubanos,” La Habana, Agenda Cambio-Debate / www.cubanet.org, 11 de junio 2010.
108. These accounts are frequently filed by independent journalists in Cuba and are available in Cubanet.org, in the Independent Press section.
109. Several personal and telephone interviews conducted with three recently exiled Cuban doctors, November and December 2009 and January 2010.
110. Stephen Dudley, “Cuban doctors defect, speak out,” The Miami Herald, Cartagena, Colombia, 15 August 2006. (For numerous reports on the lack of doctors in Cuba and the ills of Cuban healthcare see independent press reports in www.CubaNet.org and see photos of the extreme deterioration of Cuban medical facilities in www.therealcuba.com. Reports abound on the extreme lack of hygiene and the most basic medicine and supplies, broken or no medical equipment, no electricity and dilapidated facilities.)
111. The Miami Herald, 10 January 2007.
112. Feinsilver 2006.
113. “Cuba & the Global Health Workforce.”
114. Brouwer.
115. “Alternativa Bolivariana para las Américas” (ALBA), in Spanish. Cuba’s officials and the Cuban media consistently report on the medical programs and international missions within the context of ALBA.
116. The stated purpose of this alternative model is “to correct the disparities and disadvantage of underdeveloped countries compared to the developed countries.” Fernando Ramón Bossi, “Constructing the ALBA from within the peoples.” http://www.alternativabolivariana. org/modules.php?name=Content&pa=showpage&pid=258.
117. After falling ill in July of 2006, retreating from the public arena and leaving his role as President to his brother Raúl, Fidel has been dedicated to writing in Cuba’s official press on different topics as “reflections.”
118. Fidel Castro, “Christians without Bibles,” Prensa Latina, Havana, March, 3 2008. http://www.plenglish.com/article. asp?ID=%7BF9191053–F754–499C-9B65–157F7928DEAE%7D)&language=EN.
119. Feinsilver 2006.
120. The Miami Herald, Staff Report, 10 January 2007.
121. “Retornan los paraguayos que fueron a Cuba para cirugías del ojo,” ABC Color Digital, Paraguay, 13 noviembre 2005.
122. “El viaje a Cuba cuesta 10 veces más que las cirugías en Paraguay,” ABC Color Digital, Uruguay, 6 noviembre 2005.
123. “Luego de casi un mes, llegan paraguayos que fueron a Cuba,” ABC Color Digital, Paraguay, 7 de diciembre de 2005.
124. Feinsilver 1993.
125. Miguel Cabrera Peña. (The Bolivarian Committees are fashioned after the Cuban Committees for the Defense of the Revolution, which are designated citizens in all neighborhoods, a type of militia that serves as eyes and ears of the Revolution all around the country, providing round the clock supervision of and information on the population. They help with mass mobilization and have decisive input in determining who gains admittance to institutions of higher education or obtains the best employment opportunities.)
126. Ojito and personal interview with Cuban doctor, 11/21/09.
127. Stephen Dudley, “Cuban doctors defect, speak out,” The Miami Herald, Cartagena, Colombia, 15 August 2006.
128. Personal interview with Cuban doctor, 11/21/09.
129. Ojito.
130. Marc Lifsher, “Cuban Doctors in Venezuela Add To Rift Growing Between Classes,” The Wall Street Journal, May 13, 2002.
131. In 2005 it was reported that 600 members of paramilitary groups from the central provinces of Cuba were receiving intensive instruction in medical specializations with the purpose of sending them to Venezuela. (Guillermo Fariñas, “Entrenan a paramilitares como técnicos de la salud para trabajar en Venezuela,” Cubanacán Press, Santa Clara, Cuba, 24 de febrero 2005, www.cubanet.org.)
132. Álvaro Yero Felipe, “Médicos o policías,” La Habana, 7 de noviembre de 2009, www.PayoLibre.com.
133. “Cubanos en Venezuela: ¿Ayuda o interferencia?” Caracas, Associated Press, May 31, 2010.
134. See, for example, Christopher Toothaker, “Venezuela’s Chavez turns to Cuban help with energy crisis, baffling critics,” Associated Press, Caracas, February 3, 2010.
135. Jaime Daremblum, “The Cubanization of Venezuela,” The Weekly Standard, Vol. 15 No. 24, March 8, 2010.
136. Martin Arostegui, “Cuban Advisers Bolster Venezuelan Regime,” The Washington Times, April 6, 2010. “Cubanos en Venezuela: ¿Ayuda o interferencia?,” Associated Press (AP), Caracas, 31 de mayo de 2010. Roberto Koltun, “Presencia de cubanos en ‘áreas sensibles’ atenta contra el Estado,” El Universal, Caracas, 09 de enero, 2010. 137. Simon Romero, “Venezuela’s Military Ties with Cuba Stir Concerns,” The New York Times, June 14, 2010. Ian James, “Ex-general: Cubans involved in Chavez’s military,” Caracas, 4/22/2010.
138. “Venecuba, a single nation,” The Economist, February 11, 2010.
139. Carlos Alberto Montaner, “Quién encarceló a Oswaldo Alvarez Paz,” El Nuevo Herald, 3/28/10.

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